Maternal Genitourinary Infections and Adverse Perinatal Outcomes

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ClinicalTrials.gov Identifier: NCT01572532

Recruitment Status : Unknown

Verified December 2011 by Johns Hopkins Bloomberg School of Public Health. Recruitment status was: Recruiting

First Posted : April 6, 2012

Last Update Posted : August 20, 2014

Sponsor:

Johns Hopkins Bloomberg School of Public Health

Collaborators:

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

The primary aim of this study is to determine the impact of community-based screening and treatment of abnormal vaginal flora and urinary tract infections in early pregnancy (13-19 weeks) on preterm live birth in Sylhet district, Bangladesh.

Hypothesis 1: Community-based screening and treatment of abnormal vaginal flora (Nugent score >4) and urinary tract infections in early pregnancy (13-19 weeks) will reduce the population rate of preterm live birth by at least 15%.

The secondary aims of this study are:

To determine the impact of community-based screening and treatment of abnormal vaginal flora and urinary tract infections on the:

proportion of pregnancies with outcomes occurring prior to 37 weeks (late miscarriage, preterm still birth and preterm live birth); and

proportion of babies with early onset neonatal sepsis.

To determine the prevalence of abnormal vaginal flora and urinary tract infections, including asymptomatic bactiuria, among pregnant women in Sylhet district, Bangladesh.

To evaluate the accuracy of simple, low-cost, point of care diagnostic tests for detecting bacterial vaginosis and urinary tract infections by community health workers in a rural, developing country setting.

CHWs will collect urine and vaginal samples for all women enrolled. In the control clusters, every eighth woman enrolled will receive the screening-treatment protocol in order to determine the baseline prevalence of these infections in the control areas for comparison. Vaginal specimens will be collected via sterile self-administered vaginal swabs. The women will be instructed by the CHW to insert a Dacron swab ~4-5 cm into the vagina, allow the swab to stand for 15 seconds, and then rotate 360 degrees prior to withdrawal. The CHW will gently roll out the swab onto a plain glass slide and allow to air dry prior to transport to Sylhet field laboratory.

A midstream urine specimen will be obtained for urine culture. The mother will be instructed to separate the labia and collect 20-30mL of midstream urine into a sterile container which will be immediately refrigerated in a cool specimen box.

Other: Screening treatment and referral

Women who are symptomatic at any study visit will be immediately referred to the sub-district hospital for full evaluation and treatment and will be visited on the following day to follow clinical status and ensure referral compliance. Referral will be reinforced by arranging transportation to the sub-district hospital and payment of hospital fees if the family is unable to afford out-of-pocket expenses. CHWs will conduct a home visit to women with positive test results within 24 hours of receiving the results to initiate treatment. All asymptomatic women will be treated for positive test results. For symptomatic women, the CHW will confirm the woman's clinical and treatment status, and provide treatment to those women who have not already received the appropriate treatment at the sub-district hospital for their infection.

Standard care will be administered, including antenatal and postnatal care. In the control clusters, every eighth woman enrolled will receive the screening-treatment protocol in order to determine the baseline prevalence of these infections in the control areas for comparison.

Number of preterm births reduced by community-based screening and treatment of abnormal vaginal flora and urinary tract infections in early pregnancy (13-19 weeks) [ Time Frame: 5 years ]

Determine the impact of community-based screening and treatment of abnormal vaginal flora and urinary tract infections in early pregnancy (13-19 weeks) on preterm live birth in Sylhet district, Bangladesh.

Secondary Outcome Measures :

Proportion of early outcomes [ Time Frame: 5 years ]

Proportion of pregnancies with outcomes occurring prior to 37 weeks (late miscarriage, preterm still birth and preterm live birth) in Sylhet, Bangladesh

Proportion of infants with neonatal sepsis [ Time Frame: 5 years ]

Proportion of babies with early onset neonatal sepsis in Sylhet, Bangladesh

Accuracy of simple, low-cost, point of care diagnostic tests for detecting bacterial vaginosis and urinary tract infections by community health workers in a rural, developing country setting (Sylhet, Bangladesh)

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Ages Eligible for Study:

up to 47 Years (Child, Adult)

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Yes

Criteria

Inclusion Criteria:

All women who become pregnant in the study area will be eligible to participate in the trial. We will identify women with missed periods through monthly surveillance by health workers and identify pregnant women by positive pregnancy test conducted by CHWs. Thus enrollment may begin as soon as 5 weeks gestation and will continue until 19 weeks gestation. A sample of women who are enrolled early in gestation (<12 weeks), will be considered for enrolment in the gestational age sub-study. The first CHW visit for screening for abnormal vaginal flora and urinary tract infection will occur after the initial enrollment between 13-19 weeks. Their infants will enrolled as well.

Exclusion Criteria:

Subjects will be excluded from the study if they have no recall or uncertain report of LMP (due to lactational amenorrhea, recent discontinuation of contraceptive or irregular menses), history of irregular bleeding due to injectable depoprovera, or history of severe chronic disease based on their self-reported history on a medical history checklist. For women reporting a missed period during pregnancy surveillance, the CHW will perform a urine pregnancy test to confirm the pregnancy and keep a log of all positive pregnancy tests and LMP.

Pregnant women who are uncertain or refuse to participate at the initial visit will be allowed time to consider and enroll at the next study visit if they still meet inclusion criteria. Women will be given information regarding the study and CHWs will answer questions for both themselves and the family. If a woman is not certain whether she would like to participate, she will be allowed 1 week to consider participation, and the CHW will return in 1 week to revisit participation and answer any additional questions. If the woman refuses to participate at any visit, she will no longer be approached to participate.

Families can withdraw from the study at any time, and study staff will be available to answer questions families may have at any time.